Name of Referrer GDC NumberPractice NamePhone/MobileEmailAddressFull Address CityPost CodeTitle– Select –Mr.Mrs.MissMs.Dr.Prof.Rev.First NameLast NameDate of BirthPhone/MobileEmailRelevant Medical HistoryPossibility of pregnancy Yes NoHow would you like to receive the scan ? Dropbox WeTransferHas the patient informed about fee (referred to fee list) ? Yes NoIs the patient coming with a radiographic stent ? Yes NoWhich areas would you like the scan to cover?– Types Of Scan –CT ScanOPG ScanIntra – Oral 3D Scan– CT Scan –40 x 40 Endo40 x 4040 x 8080 x 4080 x 5080 x 80100 x 40 One full Jaw bone region100 x 50 One Jaw Full root length100 x 80 Full upper and Lower Jaw– OPG –Full OPGLeft Sectional OPGRight Sectional OPG– Intra Oral 3D Scan –Full Upper And Lower JawUpper Jaw OnlyLower Jaw OnlyUpper Right Teeth UR 1 UR 2 UR 3 UR 4 UR 5 UR 6 UR 7 UR 8Upper Left Teeth UL 1 UL 2 UL 3 UL 4 UL 5 UL 6 UL 7 UL 8Lower Right Teeth LL 8 LL 7 LL 6 LL 5 LL 4 LL 3 LL 2 LL 1Lower Right Teeth LR 8 LR 7 LR 6 LR 5 LR 4 LR 3 LR 2 LR 1Would you like our radiologist to write a radiology report of the scan? Yes NoJustification for scan Implants Bone Graft Periodontal Assessment Post-Op Low Dose Endodontics Sinus Examination TMJ Assessment Oral Pathology Impacted Teeth Orthodontics OtherFile UploadChoose File Submitted ByDate of ReferralSubmit Form